Uninsured Rate Rose Again in 2019, Further Eroding Earlier Progress
The number and share of Americans without health insurance coverage rose for the third consecutive year in 2019, according to data released today from the American Community Survey (ACS), Census’ larger annual survey and the more suitable data source for examining the year-to-year change in the uninsured rate. Some 9.2 percent of Americans — 29.6 million people — were uninsured in 2019, compared to 8.9 percent (28.6 million) in 2018, ACS data show.
Despite three years of strong economic growth and falling unemployment, 2019’s uninsured rate was well above 2016’s historic low of 8.6 percent, according to the ACS data. (See Figure 1.) As a result, the nation entered the COVID-19 pandemic with some 2.3 million more people uninsured than in 2016, including over 700,000 children. This is likely due in substantial part to Trump Administration policies that depressed enrollment in Medicaid and marketplace coverage.
"Despite three years of strong economic growth and falling unemployment, 2019’s uninsured rate was well above 2016’s historic low of 8.6 percent, according to the ACS data."
The Census Bureau today advised against using data from the other survey it released, the Current Population Survey (CPS), to look at health insurance changes for 2019. While the ACS data were collected in 2019, prior to the pandemic, most of the CPS data were collected in March and April of this year. Reduced response rates, especially among lower-income people, appear to have distorted the results and likely explain why the CPS shows a drop in uninsured rates in 2019, while both the ACS and the Centers for Disease Control and Prevention’s National Health Interview Survey (NHIS) show an increase.
Administration Policies a Likely Factor
The new Census data indicate that Administration policies have eroded a small but meaningful share of the historic gains in insurance coverage achieved under the Affordable Care Act (ACA). Coverage losses occurred during a period when — absent policy changes — uninsured rates would have been expected to remain stable or decline, given the significant drop in unemployment and several states’ implementation of Medicaid expansion.
Among the policies likely contributing to rising uninsured rates:
- The Administration’s harsh stance against immigrants — including changing how an individual’s participation in Medicaid could affect their ability to become a lawful permanent resident or enter (or re-enter) the United States — have sowed fear and confusion among families that include immigrant members, likely lowering enrollment in public coverage programs and raising uninsured rates. The new Census data show that Hispanic adults, Hispanic children, and children who were not born in the United States all experienced much larger-than-average increases in uninsured rates. The Hispanic uninsured rate rose in 2019 to 18.7 percent from 17.9 percent in 2018, the largest increase of any racial or ethnic group.
- The Administration’s support for state policies that make it harder to enroll or stay enrolled in Medicaid, such as procedural barriers to getting and keeping Medicaid coverage, likely contributed to the significant enrollment declines among children and adults in 2018 and 2019. Administrative data show that the number of people with Medicaid coverage fell by 2.4 million between December 2017 and December 2019. Likewise, the ACS data show that the number of people with Medicaid fell in both 2018 and 2019.
- The President and Congress repealed the ACA’s individual mandate (the requirement that most people have coverage or pay a penalty) effective in 2019. Repeal of the mandate likely contributed to the increase in uninsured rates for middle-income people evident in the Census data.
- Cuts to outreach and enrollment assistance and support have reduced enrollment in the ACA marketplaces below the levels expected if the Administration had maintained robust outreach programs.
Uninsured Rate Still Well Below Pre-ACA Levels
Despite the backsliding of the last few years, the uninsured rate remains well below pre-ACA levels. As Figure 1 shows, ACS data show that the uninsured rate plummeted from 15.5 percent in 2010 to 8.6 percent in 2016. Other data show that 2016’s uninsured rate was the lowest since data collection began in 1963 — and that the drop as the ACA’s major provisions took effect was the sharpest since the creation of Medicare and Medicaid.
The health coverage gains under the ACA have been greatest in the 32 states (including the District of Columbia) that extended Medicaid to more low-income adults by January 2019, under the ACA’s Medicaid expansion. (See Figure 2.)
Had the uninsured rate fallen in non-expansion states as much since 2013 as it did in expansion states, 4.3 million fewer Americans would have been uninsured in 2019.
Maine and Virginia newly implemented Medicaid expansion in 2019. In Virginia, the uninsured rate fell to 7.9 percent in 2019 from 8.8 percent the previous year, the largest decrease of any state. In Maine, the uninsured rate remained stable in 2019 at 8.0 percent.
Uninsured Rate Likely Headed Higher in 2020 Even Without Recession
The Census data unfortunately offer no insight about the impact of the COVID-19 recession on health coverage. While the uninsured rate will very likely rise due to the recession, the availability of Medicaid and marketplace coverage will mitigate the increase. Medicaid enrollment in 30 states with available data grew by 8.4 percent between February and July, and enrollment for adults covered through the ACA expansion grew by 12.9 percent across 18 states. Extrapolated nationwide, these figures imply that Medicaid is covering some 6 million people who might otherwise have become uninsured, about 1.5 million of them through expansion. There is also some evidence of ACA marketplace enrollment increases due to the recession, with more people enrolling through special enrollment periods this spring than in the same months of 2019.
But even as the recession leads more people to turn to ACA programs for coverage, the Administration continues to urge the Supreme Court to overturn the entire law, filing its latest brief just last month. Prior to the recession, Urban Institute researchers estimated that 20 million people would lose coverage if the ACA were repealed. With more people depending on ACA coverage programs during this recession, repeal would have an even greater impact, driving the uninsured rate back above its pre-ACA level.
 Katherine Keisler-Starkey and Lisa N. Bunch, “Health Insurance Coverage in the United States: 2019,” Census Bureau, September 2020, https://www.census.gov/content/dam/Census/library/publications/2020/demo/p60-271.pdf.
 The uninsured rate among only those people under age 65 has increased slightly more, from 10.0 percent in 2016 to 10.8 percent in 2019.
 CPS data for 2019 were collected in February through April 2020. Census noted the challenges of data collection during this time and the significantly higher non-response rate, especially among lower-income people, creating the potential for bias in the sample that would impact CPS results. Thus, the Census report published today stated, “[This report] primarily uses the ACS 1-year estimates to examine coverage for key population and to compare changes in coverage between 2018 and 2019. ACS 1-year estimates data were collected during 2019, and thus, data collection occurred before the COVID-19 pandemic.”
 The NHIS shows that the uninsured rate rose to 10.3 percent in 2019 from 9.4 percent in 2018. While changes in the NHIS methodology could have affected the results, CDC’s initial testing shows that even with these changes, the 2019 estimates of the uninsured rate for non-elderly adults can be compared to estimates from previous years. For the CDC’s explanation of the 2019 NHIS questionnaire redesign, see https://www.cdc.gov/nchs/data/nhis/earlyrelease/EReval202005-508.pdf.
 Jennifer Haley et al., “One in Five Adults in Immigrant Families with Children Reported Chilling Effects on Public Benefit Receipt in 2019,” Urban Institute, June 18, 2020, https://www.urban.org/research/publication/one-five-adults-immigrant-families-children-reported-chilling-effects-public-benefit-receipt-2019.
 Matt Broaddus, “Research Note: Medicaid Enrollment Decline Among Adults and Children Too Large to Be Explained by Falling Unemployment,” Center on Budget and Policy Priorities, July 17, 2019, https://www.cbpp.org/research/health/medicaid-enrollment-decline-among-adults-and-children-too-large-to-be-explained-by.
 Centers for Medicare & Medicaid Services, “Medicaid & CHIP Enrollment Data,” https://www.medicaid.gov/medicaid/national-medicaid-chip-program-information/medicaid-chip-enrollment-data/index.html.
 Centers for Medicare & Medicaid Services, “Trends in Subsidized and Unsubsidized Enrollment,” August 12, 2019, https://www.cms.gov/CCIIO/Resources/Forms-Reports-and-Other-Resources/Downloads/Trends-Subsidized-Unsubsidized-Enrollment-BY17-18.pdf.
 Council of Economic Advisers, “2017 Economic Report of the President,” December 15, 2016, https://obamawhitehouse.archives.gov/sites/default/files/docs/2017_economic_report_of_president.pdf.
 CBPP analysis using ACS data for 2013 through 2018. Medicaid expansion states are defined as states that had implemented the ACA Medicaid expansion to low-income adults by January 2018.
 Matt Broaddus, “Medicaid Enrollment Continues to Rise,” Center on Budget and Policy Priorities, September 9, 2020, https://www.cbpp.org/blog/medicaid-enrollment-continues-to-rise.
 Sarah Lueck and Matt Broaddus, “Emergency Special Enrollment Period Would Boost Health Coverage Access at a Critical Time,” Center on Budget and Policy Priorities, July 30, 2020, https://www.cbpp.org/research/health/emergency-special-enrollment-period-would-boost-health-coverage-access-at-a-critical.
 Linda Blumberg et al., “State-by-State Estimates of the Coverage and Funding Consequences of Full Repeal of the ACA,” Urban Institute, March 2019, https://www.urban.org/sites/default/files/publication/100000/repeal_of_the_aca_by_state.pdf.